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The District of Columbia published its first draft transition plan and proposed waiver amendments in the D.C. Register on March 28, 2014, which began a 30- day public comment period. CMS reviewed the draft transition plan and recommended changes. Based on those recommendations from CMS, D.C. revised its Transition Plan and published it and the proposed waiver amendments in the D.C. Register on October 31, 2014 and again on November 28, 2014, allowing the public to benefit from an extended public comment period. The following comments were given in response to the proposed waiver amendments that were published in the D.C. Register on October 31, 2014 and November 28, 2014.Waiver Service StakeholderCommentsAmendment LanguageDDS Initial ResponseDDS/DHCF Final ResponseCreative Arts Therapies(group rate)The Art and Drama Therapy Institute, Inc.(Dr. Sirkku M. Sky Hiltunen)Commenter is concerned that the 4 reports (session and quarterly) cannot be written in 15 minutes. Commenter recommends the group rate be set for $30 to allow therapists to write 4 reports (session and quarterly.Proposed group rate $22 for a group of 4.Agree to raise the rate to $25 to align with other therapies. (See Appendix J, Waiver Amendments) Fitness(decreased rate)The Art and Drama Therapy Institute, menter concerned that the decreased rate for fitness to $50 seems drastic. Recommends the rate be set at $60 to support the credentials required for the position. Rate reduced from $75 per hour to $50 per hour.Based on public comment from multiple sources will leave the current rate unchanged at $75 per hour. (See Appendix J, Waiver Amendments) Eligibility requirements(Assets)Regina LeePerson with DisabilityCommenter recommends a change in eligibility requirements for the waiver so that a person with a whole life insurance policy may qualify. Concerned that people with whole life policies cannot spend down the value of the policy and can only borrow against it. Concerned that people who worked and invested in whole life insurance policies can never qualify for supports through a Medicaid waiver when they become disabled.N/A No change required.Asset tests related to whole-life insurance policies are based on federal requirements and are not subject to change via a state waiver amendment.Wellness and Fitness RateOji Fit World(Amaka Oji)Commenter is concerned that the proposed amendment to reduce the Wellness and Fitness rate will negatively impact the fight against obesity, the health and welfare of individuals and families and Oji Fit World will suffer abrupt financial affliction. The rate does not take into consideration the market rate for fitness training in this region ($85-$125 per hour and $40-$65 per 30 minute session). It also does not consider the cost of living expenses in DC. (Family of four needs $88,615 to live in DC.) Based on current market conditions, DDS proposes to reduce the rate from $75 to $50 per hour and to introduce a group rate of $30 per hour for a group of two.Based on public comment from multiple sources will leave the current rate unchanged at $75 per hour and increase the group rate to $45 per hour for a group of two. (See Appendix J, Waiver Amendments)Wellness and Fitness RateOji Fit WorldDDS should consider increasing the rate from$75 to $95 per hour and a group rate of $60 for a group of two attract more qualified fitness agencies to work with individuals with disabilities.Based on current market conditions, DDS proposes to reduce the rate from $75 to $50 per hour and to introduce a group rate of $30 per hour for a group of two.Based on public comment from multiple sources will leave the current rate unchanged at $75 per hour and increase the group rate to $45 per hour for a group of two. (See Appendix J, Waiver Amendments)Special Payment Rates for Services to Deaf ConsumersDeaf-REACHSarah E. Brown, Executive DirectorDDS should develop an increased rate of payment for services provided to deaf consumers. Commenter suggests increasing rates by 35% to providers for services to deaf consumers as Medicaid has agreed to in the Department of Behavioral Health waiver.Reference DHCF Notice of Emergency and Proposed Rulemaking to establish reimbursement rates to Department of Behavioral Health certified mental health providers for Mental Health Rehabilitation Services provided to consumers who are deaf or hearing-impaired.DDS agrees to research and implement an enhanced rate for services provided to consumers who are deaf or hearing- impaired.Wellness and Fitness RateFamily Advocate (justjone10@)Proposed rate of $50 per hour is too low and would result in the trainer receiving net pay of $12 an hour, if consider travel expenses and time.Based on current market conditions, DDS proposes to reduce the rate from $75 to $50 per hour and to introduce a group rate of $30 per hour for a group of two.Based on public comment from multiple sources will leave the current rate unchanged at $75 and increase the group rate to $45 per hour for a group of two.General - Outcomes measurementFamily Advocate (justjone10@)DDS staff should be required to report when services yield no results. DDS will incorporate this recommendation into changes in policy and procedure for monitoring the Individual Service Plan.GeneralFamily Advocate (justjone10@)Referring to DHCF and DDS proposed rule makings as an emergency is illegal according to the DC Municipal Regulations.General commentNo change required.Day Hab MealFamily Advocate (justjone10@)Meals should be provided for people in day programs who reside in their natural homes and for those who live in group homes.Nutritional adequate meal to be provided for people who live independently or with their families.No change required. DDS already provides funding for meals for people who use residential supports through Human Care Agreements. Providing meals during day hab for people who reside in group homes would create a double-payment and is not permissible.Day HabilitationFamily Advocate (justjone10@)Day program providers should provide community outings that reflect freedom of choice. Many outings, such as those to the Goodwill or to the recreation center are boring and not interesting or meaningful.General commentDDS will add the following language to the Day Habilitation service definition:The service shall offer adult, skill building activities, including opportunities for community exploration, inclusion and integration, based upon the person’s current, emerging and newly discovered interests and preferences.? The activities shall support the acquisition of new skills as well as support for self-determination, the development of relationships, community integration, employment exploration and/ or community contribution.? (See page 57, Day Habilitation service definition) Day HabilitationFamily Advocate (justjone10@)Day Program providers should be required to report injuries that occur to people while in the community.-No change required. This is already a requirement of all waiver providers, including Day Programs, per policy regardless of where the incident plaint Tracking LogFamily Advocate (justjone110@)Please give clear guidance about incident reporting and DDS role of informing the individual regarding the outcomes of investigation. Commenter states that pages 180-183 give conflicting information about complaint tracking.See waiver pages 180 -183 regarding the tracking of complaints.DDS will amend the waiver related to investigator follow up. Currently, it is to be done within 24 hours but the requirement has changed to 72 hours in the most recent procedure update. Under current IMEU procedure, the provider is responsible for informing the person of the investigation outcomes. Companion ServicesPublic Forum participant (12/8)Commenter was impressed with the inclusion of the companion service in the waiver amendments. Commenter feels this would be very good for some people who are not interested in habilitation but still may want to engage with another person during the day.No change required.DDS agrees that companion is an important addition, for example, for a person who is of retirement age and no longer wishes to work or attend a day program every day. EAA and PERSDC Coalition of Disability ServicesThe commenter recommends Environmental Accessibility and Personal Emergency Response System be removed from the list of services that are prohibited from being reimbursed if they are billed for the same day of service as Host Home. These services are not provided on a daily basis and would only be required in an emergency situation.Host Homes service may not be used if it isbilled for the same day of service that the following ID/DD Waiver services are provided: Residential Habilitation, Supported Living, In-Home Supports, Personal Care Services, and EAA.DDS agrees and has removed EAA from the list of services that are prohibited from being used if they are billed for the same day of service as Host Home. (See page 97 of the Waiver Amendments) EAA: The current service definition allows the use of EAA in rental or leased property with the written approval of the landlord and approval of DDS. DDS will amend the service definition to include rental, leased, or HOST HOME property with the written approval of the landlord or HOST HOME FAMILY and approval of DDS. (See page 89 of Waiver Amendments)PERS: DDS agrees, but no change is required. The current service definition for PERS states: “PERS services are available to those individuals who live alone, who are alone for significant parts of the day, or who would otherwise require extensive routine supervision.” PERS is not currently excluded in the service limitation section for Host Homes. Supported Living with TransportationNovember 17, 2014Public Forum CommentersTwo commenters said that not all cabs in DC are accessible to people with disabilities and this is a barrier to community integration. Sometimes cabs that are accessible aren’t available when they’re needed.Supported Living with Transportation is provided in a home that is owned or leased and operated by the agency, or owned or leased by the individual or his/her family. Transportation is included in this service to provide routine and urgent medical care transportation and facilitate community access for individuals. Individuals will continue to use State Plan emergency medical transportation services to access medicallynecessary emergency services.No change required.Transportation funding can be used for any form of transportation including provider owned/leased vehicles.Day HabilitationNovember 17, 2014 Public Forum CommenterStaff should not speak to someone else about people they support when they are present, as if they are not present. “Don’t talk about us without us.”No change required.DDS agrees. This is an indicator that DDS will include in its assessment tools for compliance with the HCBS Settings Rule. Person-Centered Thinking TrainingNovember 17, 2014 Public Forum CommenterNurses should be required to take Person Centered Thinking Training. Commenter gives an example where a nurse tried to make rules for her and didn’t honor the choice she had made for herself.Provider Requirements: Adds the requirement that owner-operators of residential, day and vocational supports complete training in Person-Centered Thinking, Supported Decision-Making, Supporting Community Integration, and any other topics determined by DDS, and in accordance with DDS published guidance within one year from the date the waiver application becomes effective for current providers and prior to any new waiver provider becoming approved to initiate services.No change required.DDS agrees that additional provider staff should be trained in PCT and will add components of PCT to the on-going nursing roundtables. DDS will address in its policy a new requirement that owner-operators, program managers, QIDDPs, and house managers will complete PCT training within1 year of the amendment and within 90 days for any new hire. Person-Centered Plan/ISP MeetingNovember 17, 2014 Public Forum CommenterPeople should be able to make their own schedules and have the freedom to implement their schedules.The DDA service coordinator is responsible for informing individuals of all waiver services and offering a choice of service and providers to individuals during the Level of Care re-determination process. The DDA service coordinator will also provide individuals with a fact sheet about abuse and neglect. The DDA service coordinator is responsibleto ensure the LON assessment and report are updated on at least an annual basis, or, whenever there is a significantchange in a person's support needs as part of a review and/or amendment to the ISP if needed. On time is defined asbeing completed on or before the effective date of the annual ISP.No change required.DDS agrees. These are indicators that DDS will include in its assessment tools for compliance with the HCBS Settings Rule. Day HabilitationNovember 17, 2014 Public Forum CommenterCommenter states that having the 1:4 ratio for day programs does not work to honor everyone’s preferences, Each Day Habilitation provider shall maintain the required staff to person ratio, indicated on the person’s ISP/POC to a maximum staffing ratio of 1:4.No change required.Although the current rate for day habilitation is based on 1:4 ratio, day programs have the flexibility and are expected to work with people individually and in small groups. Residential HabilitationNovember 17, 2014 Public Forum CommenterFor people who live in group homes, there aren’t many staff members on duty at the same time and that results in people participating in activities that they are not interested in; for example if there are people who have different religions and want to attend different religious services. No change required. The rules and rates support four different levels of staffing intensity based on people’s support needs. In addition, DDS encourages people to expand the circle of natural supports, such as family, friends and neighbors, who can also help to expand options and opportunities. Vocational SupportsNovember 17, 2014 Public Forum CommenterParticipant supports the vocational training and computer classes in Supported Employment programs. He has learned how to use a computer to conduct a job search.No response panion ServicesNovember 17, 2014 Public Forum CommenterParticipant asks whether people who wish to retire, are able to access the new companion service or will they be required to go to a day panion services can be used with Residential Habilitation and 24 hour Supported Living services, but onlyduring regular daytime Monday – Friday hours, and may not exceed more than 40 hours per week, in combination with Personal Care Services or any other waiver day or vocational support services. This includes Day Habilitation, Employment Readiness, Supported Employment or Individualized Day Supports.No change required. People who are retired can use companion services, based on their assessed needs.IDSNovember 17, 2014 Public Forum CommenterParticipant asked whether matching for IDS can be with different people. For example, can someone match with one peer one week and a different peer another week?Individualized Day Supports are available both as a one-to-one service for a person, and in small group settingsnot to exceed 1:2.There is nothing in the service definition or rules that prohibit this. DDS will add clarifying language in regulations to affirmatively allow this.IDSNovember 17, 2014 Public Forum CommenterParticipants asked how DDS will take caution when hiring DSPs to do IDS, especially given that the requirement to have an associate’s degree is being eliminated. There is concern that sometimes DSPs are inexperienced. For individual employees, the following requirements apply:? Documentation that each employee is eighteen (18) years of age or older;? Annual documentation from a physician or other official that the employee is free fromcommunicable disease as confirmed by an annual purified protein derivative of tuberculin (PPD) SkinTest;? Record of completion of competency based training in communication with people with intellectualdisabilities;Record of completion of DDS approved orientation for individual employees working in Individualized Day Supports.? Record of completion of competency based training in infection control procedures consistent withthe requirements of the Occupational Safety and Health Administration, U.S. Department of Laborregulations at 29 CFR 1910. 1030.;? A high school diploma or general equivalency development;? Record of completion of competency based training in emergency procedures;? Certification in cardiopulmonary resuscitation (CPR) and First Aid;? Record of completion of DDS approved pre-service and in-service training in DDS policies andprocedures;? Training needed to address the unique support needs of the individual as detailed in their IndividualSupport Plan;? Record of criminal background check consistent with the requirements of the Health-Care FacilityUnlicensed Personnel Criminal Background Check Act of 1998, effective April 20, 1999 No change required. The pending waiver amendments require additional training for IDS DSPs.IDSNovember 17, 2014 Public Forum CommenterParticipant suggests that people receiving services should deliver the training for DSPs for IDSFor individual employees, the following requirements apply:? Documentation that each employee is eighteen (18) years of age or older;? Annual documentation from a physician or other official that the employee is free fromcommunicable disease as confirmed by an annual purified protein derivative of tuberculin (PPD) SkinTest;? Record of completion of competency based training in communication with people with intellectualdisabilities;? Record of completion of competency based training in infection control procedures consistent withthe requirements of the Occupational Safety and Health Administration, U.S. Department of Laborregulations at 29 CFR 1910. 1030.;? A high school diploma or general equivalency development;? Record of completion of competency based training in emergency procedures;? Certification in cardiopulmonary resuscitation (CPR) and First Aid;? Record of completion of DDS approved pre-service and in-service training in DDS policies andprocedures;Record of completion of DDS approved orientation for individual employees working in Individualized Day Supports.? Training needed to address the unique support needs of the individual as detailed in their IndividualSupport Plan;? Record of criminal background check consistent with the requirements of the Health-Care FacilityUnlicensed Personnel Criminal Background Check Act of 1998, effective April 20, 1999 No change required.DDS agrees people receiving services should be part of training teams. GeneralNovember 17, 2014 Public Forum CommenterParticipant says there seems to be a lack of communication between RSA and DDA.No change required. DDS has written protocols governing referrals between RSA and DDA and leadership continues to identify and address barriers.GeneralNovember 17, 2014 Public Forum CommenterParticipant asks what services DDS is using local funds to support.No change required. Local funds are used primarily for nursing oversight in the day programs, meals for people who live independently or with families at their day habilitation program, to provide a specialized rate for SL for people who require intensive (greater than 1:1) supports. All of these have been added as waiver amendments so that we can draw down FFP. Rates & Affordable Care Act November 17, 2014 Public Forum CommenterParticipant asks whether DDS has considered the impact of the ACA on how providers are providing health benefits to their DSPs. Participant says about half of staff are receiving health care benefits and they currently pay 75% of the cost and the workers pay 25%. Participant suspects that people can get cheaper health benefits through the state exchanges than what their company could provide. But 90% of DSPs are on their employers health benefits. Are the current rates reflective of the increase health benefit costs that will happen as a result of ACA?The Affordable Care Act includes a mandate for certain large employers (with over 50 full time equivalent employees) to either offer qualified and affordable health benefits, or pay a tax penalty. This is commonly referred to as the employer mandate, “play or pay” requirement, or employer shared responsibility.No change required. DDS has carefully reviewed the rates and finds them adequate to cover any accompanying changes in the cost of health insurance based on ACA requirements. General November 17, 2014 Public Forum CommenterParticipant asks whether services can be provided in the language preferred by the person.The goals of this comprehensive waiver program are to enablethese Medicaid waiver participants to: 1) lead healthy, independent, and productive lives; 2) live, work, and fully participatein their communities to the fullest extent possible; 3) fully exercise their rights as residents, and 4) promote the integrity andwell-being of their families. Further goals of this waiver are to provide these health and health-related services in a mannerthat: 5) meets each participant’s needs, goals, and preferences in the most integrated, least restrictive setting possible; and6) meets the widely accepted goals for quality health care of: safety, effectiveness, person-centeredness, timeliness,efficiency, and equity.No change required. This is already required by policy and regulation. GeneralNovember 17, 2014 Public Forum CommenterParticipant asked whether staff get to know people they are going to serve before they read their files.No change required. DDS policy requires each staff person to receive individualized training.Fitness ratesNovember 17, 2014 Public Forum CommenterParticipant asked about market rate research DDS did for fitness rates. The participant suggested that DDS take into consideration specific needs of people with disabilities and the additional time and attention trainers give for people with intellectual disabilities.Fitness: Based on current market conditions, to reduce the rate from $75 to $50 per hour, and to introduce a grouprate.Based on public comment from multiple sources will leave the current rate unchanged at $75 and increase the group rate to $45 per hour for a group of two.Fitness ratesNovember 17, 2014 Public Forum CommenterParticipant says that fitness is the one service that her family member uses and she hopes the decrease in pay doesn’t result in loss of providers for this service.Fitness: Based on current market conditions, to reduce the rate from $75 to $50 per hour, and to introduce a grouprate.Based on public comment from multiple sources will leave the current rate unchanged at $75 and increase the group rate to $45 per hour for a group of two.Fitness ratesNovember 17, 2014 Public Forum CommenterParticipant feels that as a provider of fitness services he is not just a provider but a part of the family. The decrease in the rate will make it difficult to operate. Fitness trainers for people with disabilities should get paid more than a trainer in a regular gym.Fitness: Based on current market conditions, to reduce the rate from $75 to $50 per hour, and to introduce a grouprate.Based on public comment from multiple sources will leave the current rate unchanged at $75 and increase the group rate to $45 per hour for a group of two.Fitness ratesNovember 17, 2014 Public Forum CommenterParticipant says that obesity is a problem. Fitness services currently provided in the waiver go beyond fitness. Trainers are friends, counselors, etc and go above and beyond what most fitness trainers will do. Cost of living in DC is expensive. Decreasing the rates for fitness will really hurt fitness providers.Fitness: Based on current market conditions, to reduce the rate from $75 to $50 per hour, and to introduce a grouprate.Based on public comment from multiple sources will leave the current rate unchanged at $75 and increase the group rate to $45 per hour for a group of two.General November 17, 2014 Public Forum CommenterParticipant stated that no one is holding clinicians accountable for professional services. When progress is not being made with therapy, there should be a change in therapy.No change required. DDS is building new qualitative measures for evaluating clinicians. DDS also has a major recruitment effort for new clinicians.Rates – General, Day HabilitationADTI (Dr. Sky)Commenter says that DDS seems to set rates using a “cookie cutter” model that does not work and does not pay adequately for a variety of service models. Gives an example of costs incurred for a small specialized provider with facility rent being different from a service provider with multiple residential facilities and a day habilitation program with no building or minimal rent. No change required. The waiver amendment includes 5 different rates for day/vocational services not including Supported Employment.Rates - Day HabilitationADTI (Dr. Sky)Commenter states that the new rate modifier does not cover the actual cost of meals, because DSPs should not be preparing meals, distributing them or cleaning up after meals. Suggests that staff with food handler licenses should be hired to perform such duties to allow DSPs to have a lunch break. No change required. DDS agrees that a Food Handlers license is required to prepare meals. Art TherapiesADTI (Dr. Sky)Commenter is grateful for the name change but the name is still incomplete. Name should be “The Creative Arts Therapies (visual arts, music, dance, and drama/theater) and should list all different arts therapies.DDS agrees to change the name to Creative Arts Therapies. (See page 56 and pages throughout Waiver Amendments)Rates - Art TherapiesADTI (Dr. Sky)The group rate of $22 does not cover the actual cost of providing service. Commenter suggests increasing the group rate to $35 to adequately allow additional time to write the session notes, quarterly and annual reports for 4 participants. Art Therapies group rate is $22.38 for 45 minutes.DDS agrees to raise the rate to $25 to align with other therapies. (See Appendix J.)Rates - Art TherapiesADTI (Dr. Sky)Commenter also states that attendance in ISP meetings is not feasible. The provided report should adequately represent the professional in those meetings. The rate doesn’t cover attendance at the ISP meetings that may last for up to 2.5 hours nor does the rate cover travel time to the meetings. Commenter is requesting that the requirement to attend ISP meetings be eliminated from the regulations and from the language in the ISP.Art Therapies rates are $76.73 for 45 minutes. Music therapy and art therapy group rates are $22.38 for 45 minutes. Art therapies may be utilized to “providenecessary information to the individual, family, caregivers, and/or team to assist in planning and implementing plans per the approved ISP/Plan of Care.”No change required.DDS firmly believes that all team members be available as requested by the person to participate in planning meetings.Rates - FitnessADTI (Dr. Sky)Commenter believes the decrease in rate is unjustified. The cost of the equipment should also be considered. Commenter is asking DDS to retain the rate of $75/hour. Fitness: Based on current market conditions, to reduce the rate from $75 to $50 per hour, and to introduce a group rate of $27 an hour.Based on public comment from multiple sources will leave the current rate unchanged at $75 per hour and increase the group rate to $45 per hour for a group of two.Rates - FitnessADTI (Dr. Sky)Commenter says that the statement about small group is unclear. There is no rate modification for the small group rate which should be $50/hour.Fitness group rate - $27/hourBased on public comment from multiple sources will leave the current rate unchanged at $75 per hour and increase the group rate to $45 per hour for a group of two.Grief CounselingADTI (Dr. Sky)Commenter says that service provider qualifications need to be changed to require the professional be either a Licensed Professional Counselor or a creative arts therapist with a minimum of two years of experience in the field. Counseling persons with intellectual disabilities requires the ability to utilize nonverbal communication to reach people and offer them enough opportunities to express feelings, thoughts and make choices. Verbal therapies do not work alone. Therefore, commenter is requesting that DDS eliminate specific grief counseling license requirements.Bereavement Counselors are required to be licensed in accordance with District of Columbia Health Occupations Revisions Act of 1985,effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code §§ 3-1201 et seq. (2007 Rep. & 2012Supp.)) and be certified grief counselors by the American Academy of Grief Counseling.No change required. DDS disagrees with the comments and will keep professional requirements.Rates - GeneralADTI (Dr. Sky)Commenter states concern that Director Nuss mentioned during her December 18th presentation that residential providers have opportunities to make profits when small day providers like ADTI have sustained losses since the beginning of the waiver program. The waiver program contains unfunded mandates in addition to essential services for which small day providers are responsible. Commenter suggests a discriminatory practice by DHCF and DDS that offers raises, perks and opportunities for profit for providers based on the Level of Need (LON) of each person served. ADTI will not have the benefit of receiving elevated rates due to the LON of the people they ments from Director Nuss’ December 18, 2014 presentation during Provider Leadership Meeting.No change required. Director Nuss believes any such reference to profit if made was taken out of context. The waiver amendment addresses support needs of persons with significant support needs. ADTI is also not a “small provider” but rather is the largest day program in the District. Rates Presentation 12/18/2014ADTI (Dr. Sky)Presentation on rate structure and development contained many errors. Commenter wants to know why copies of the rate structure for Day Habilitation were not emailed to providers prior to the meeting as were other proposed rate structure charts. No change required. The Day Habilitation rate structure was distributed prior to the meeting and posted on the DDS web site.Rates PresentationADTI (Dr. Sky)Rate structures seem arbitrary and decreased often without proper or logical justifications.No change required. The rate structures have been vetted numerous times with the OCFO staff and provider representatives.GeneralADTI (Dr. Sky)Development of amendments has been delayed unnecessarily. No change required. The amendment has been delayed by the inability of the District to obtain approval from CMS for its IDD HCBS waiver Transition Plan.GeneralADTI (Dr. Sky)Amendments are full of errors and use discriminatory practices.No change required. DDS does not agree that the amendment contains discriminatory practices.GeneralADTI (Dr. Sky)The closing of providers businesses have been based on racial profiling. Caucasian owned companies seem to be doing well compared to minority businesses. Minority owned businesses seem to receive constant scrutiny, harassment, bullying and are being closed.No change required. DDS implements its quality assurance and improvement system without regard to company ownership.Day Habilitation - NursingADTI (Dr. Sky)Commenter states that the ratio and other specifics must be more clearly stated and defined. Commenter believes there were too many changes. Commenter asks whether a nurse will be added for every 1:20 ratio of people? DDS should explain in more detail what the actual criterion is. The annual salary does not include the additional cost of benefits.The Day Habilitation services rate methodology to be changed to include nursing for staff training and oversight of Health Care Management Plans (HCMPs) at a ratio of 1:25 to be paid at the rate for a Registered Nurse of $72,800. No change required. The rate methodology has been updated to include funding for an RN at an annual salary of $72,800 plus benefits at a ratio of 1 to every 25 people supported. (See Appendix J)Person-Centered Thinking – DDS Service CoordinatorsADTI (Dr. Sky)Commenter says there seems to be a pre-set negative targeting of certain identified Day Program providers.No change required. DDS will be developing new policies and procedures on provider choice and welcomes public comment.Person-Centered Thinking – DDS Service CoordinatorsADTI (Dr. Sky)When a person has made a choice, the SC declares that the team has influenced the person’s choice.No change required. DDS will be developing new policies and procedures on provider choice and welcomes public comment.Person-Centered Thinking – DDS Service CoordinatorsADTI (Dr. Sky)There are times when the SC makes decisions for the person. No change required. DDS will be developing new policies and procedures on provider choice and welcomes public comment.Person-Centered Thinking – DDS Service CoordinatorsADTI (Dr. Sky)The SC may open an ISP meeting and state the choice of the person was expressed prior to the ISP meeting with no evidence of that choice being made by the person. The SC will then convince the team that she has intimate knowledge of what the person likes and dislikes.No change required. DDS will be developing new policies and procedures on provider choice and welcomes public comment.Individual Day SupportsADTI (Dr. Sky)SE staffCommenter asks how relatives will be able to provide DSP services for people. What is the criterion for such a family member?Proposed amendment for Individualized Day Supports allows relatives to provide DSP services for the person.No change required. Family members must meet the same requirements as any other person to deliver services. Individual Day SupportsADTI (Dr. Sky)SE staffCommenter asks how there will be a decrease in rate when the new program has not started?Individualized Day Supports rate to be reduced from $24.44 per hour to $21.79 per hour, based on market research and to promote parity with other individualized supports.No change required. Individualized Day Services has been operating for over six months.Individual Day SupportsADTI (Dr. Sky)SE staffCommenter says DDS needs to consider the problems DSPs will be facing while in the community.No change required. DDS expects the provider to utilize qualified and well trained staff and innovative methods of supervision. The waiver amendments include additional training requirements for IDS DSPs.Intensive Individualized Supported LivingADTI (Dr. Sky)SE staffCommenter says that the medical 1:1 service rate should be equal or higher than IDS.Intensive Individualized Supported Living: Provides intensive individualized staffing at a greater than 1:1ratio to support a person due to complex behaviors that may involve a serious risk to thehealth safety or well-being of the person or others, or when required by court order. No change required. There is no relationship between individualized supported living and IDS.Supported EmploymentADTI (Dr. Sky)SE staffWhen will modified provider qualifications be in effect?Provider enrolled to provide services through DDS/DHCF and has current MedicaidAgreement. Provider must become an RSA Supported Employment provider within one year of theapproval date of the waiver amendments.For individual employees, the following requirements apply:- Documentation that each employee is eighteen (18) years of age or older;- Documentation that each employee was found acceptable by the individual- Annual documentation from a physician or other official that the employees is free from communicable diseases as confirmed by an annual purified protein as confirmed by an annual purified protein derivative of tuberculin (PPD) Skin Test;- Record of completion of competency based training in communication with people with intellectualdisabilities- Record of completion of competency based training in infection control procedures consistent withthe requirements of the Occupational Safety and Health Administration, U.S. Department of Laborregulations at 29 CFR 1910. 1030;- A high school diploma or general equivalency development;- Certification (annual) in cardiopulmonary resuscitation (CPR) and First Aid;- Record of completion of DDC approved pre-services and in-service training in DDS policies andprocedures;No change required. Within one year of approval of the waiver amendment.Rate changes - Behavior SupportADTI (Dr. Sky)SE staffCan the Behavior Specialist working in the Day Program benefit from the new rates?No change required. Yes.Employment ReadinessADTI (Dr. Sky)QA staffCommenter is concerned that the bachelor’s degree level qualifications in vocational rehabilitation are not supported by the pay scale at $17.04/hour.For individual employees, the following requirements apply:? Documentation that each employee is eighteen (18) years of age or older;? Annual documentation from a physician or other official stating that employee is free fromcommunicable disease as confirmed by an annual purified protein derivative of tuberculin (PPD) SkinTest;? Record of completion of competency based training in communication with people with intellectualdisabilities;? Record of completion of competency based training in infection control procedures consistent withthe requirements of the Occupational Safety and Health Administration, U.S. Department of Laborregulations at 29 CFR 1910. 1030;? A high school diploma or general equivalency development;? (GED) certificate from English speaking program or ESL certificate;? Record of completion of competency based training in emergency procedures;? Certification (active) in cardiopulmonary resuscitation (CPR) and First Aid;? Record of completion of DDS approved pre-service and in-service training in DDS policies andprocedures;? Training needed to address the unique support needs of the individual as detailed in their ISP.Noted and DDS is evaluating whether rates can be aligned with the RSA Supported Employment rate methodology.Employment ReadinessADTI QA staffCommenter believes that ER providers should receive an increased payment rate comparable to that of Day Hab providers based on the following justification: 1. ER requires person-centered vocational and situational assessment, if completed within the first 90 days of participation and annually thereafter (Waiver Standard 1922.6) 2. Employment Readiness assessments should be provided at a community business and/or other community settings.The rate for ER has also been increased. (See Appendix J) Employment ReadinessADTI QA staffCommenter states that it is unclear how supports will be provided in the volunteer work situation if a person secures a volunteer job which would require 1:1 support (Waiver Standard 1922.5)No change required. Employment Readiness would not be the appropriate service in that instance.Employment ReadinessADTI QA staffCommenter suggests DDS consider a bachelor’s degree level qualification requirement for vocational rehabilitation staff.For individual employees, the following requirements apply:? Documentation that each employee is eighteen (18) years of age or older;? Annual documentation from a physician or other official stating that employee is free fromcommunicable disease as confirmed by an annual purified protein derivative of tuberculin (PPD) SkinTest;? Record of completion of competency based training in communication with people with intellectualdisabilities;? Record of completion of competency based training in infection control procedures consistent withthe requirements of the Occupational Safety and Health Administration, U.S. Department of Laborregulations at 29 CFR 1910. 1030;? A high school diploma or general equivalency development;? (GED) certificate from English speaking program or ESL certificate;? Record of completion of competency based training in emergency procedures;? Certification (active) in cardiopulmonary resuscitation (CPR) and First Aid;? Record of completion of DDS approved pre-service and in-service training in DDS policies andprocedures;? Training needed to address the unique support needs of the individual as detailed in their ISP.No change required. This is not applicable to the waiver.Employment ReadinessADTI QA staffCommenter suggests DDS consider more intense levels of vocational assessment types.No change required. DDS supports an array of vocational assessments.Employment ReadinessADTI QA staffCommenter suggests DDS consider volunteer job-site staffing and supports (these placements are time-limited according to the rules (Waiver Standard 1922.5)No change required. DDS supports paid employment as the service outcome. Day Habilitation ADTI QA staffCommenter points out that there is only one assessment requirement – functional analysis, first 90 days and annually thereafter (Waiver Standard 1920.10) (Implied comparison to Employment Readiness assessment requirement.)ER requires person-centered vocational and situational assessment, if completed within the first 90 days of participation and annually thereafter (Waiver Standard 1922.6) 2. Employment Readiness assessments should be provided at a community business and/or other community settings.No change required. Day HabilitationADTI QA staffCommenter states that rate for Day Hab is now $26.72 per hour inclusive of meals (persons in natural homes), cell phones and nursing services. (Implied comparison to ER which pays a lower rate.)Increase in the Employment Readiness rate from $3.80 to $5.26 per 15 minute unit based upon increased costs in capital and indirect costs.No change required. Noted. The ER rate has increased as well.Small Group Day HabilitationDecember 23, 2014 meeting with Amy Brooks, Arthur Ginsburg, Ron JamesSuggests that DDS consider different levels of small group day habilitation. For example, one that specializes in therapies and has OT/PT/ST on site and another that focuses on cultural arts. Rates would be different based on the specialized service offered by the provider.No change required. Noted for future amendments.Small Group Day HabilitationDecember 23, 2014 meeting with Amy Brooks, Arthur Ginsburg, Ron JamesSuggests that DDS consider having different allowable sizes based upon service focus.No change required. Noted for future amendments.Small Group Day HabilitationDecember 23, 2014 meeting with Amy Brooks, Arthur Ginsburg, Ron JamesSuggests that DDS allow flexibility to have variations in the day habilitation services and rates to accommodate different programs with different intensities and focuses.No change required. Noted for future amendments.Small Group Day HabilitationDecember 23, 2014 meeting with Amy Brooks, Arthur Ginsburg, Ron JamesGroup expressed concern about overhead costs for small group day habilitation. Suggested price per square foot may be higher in smaller units (compared to traditional day hab). No change required. Noted for future amendments.Small Group Day HabilitationDecember 23, 2014 meeting with Amy Brooks, Arthur Ginsburg, Ron JamesSmall group day habilitation needs to be located in places that are prominent in the community to allow the community to flow in as well as having people go out throughout the day.DDS agrees.Proposed amendment: Small group day habilitation cannot be provided in the same building as a large day habilitation facility setting and must be located in places that facilitate community integration and inclusion. No more than 15 people can be supported in small day habilitation. (See page 57 of the Waiver Amendments)Small Group Day HabilitationDecember 23, 2014 meeting with Amy Brooks, Arthur Ginsburg, Ron JamesTransportation costs for small group day habilitation seem as though they would be higher than calculated in the rate. Assume 2 groups of 1-2 people going out each day.Noted and rates will be adjusted to reflect transportation costs. (See Appendix J)Small Group Day HabilitationDecember 23, 2014 meeting with Amy Brooks, Arthur Ginsburg, Ron JamesStandards for qualified providers for small group day habilitation should include prior experience in supporting people who are medically or behaviorally complex (not as an absolute but as a strong indicator). Providers should also describe and demonstrate their vision; require staff rosters to indicate clinical team availability. Providers should be able to demonstrate business acumen and should have been trained in PCT.Each day habilitation services provider shall:(a) Meet the applicable requirements to conduct business in the state in which the provider deliversservice;(b) Have a current District of Columbia Medicaid Provider Agreement that authorizes the provider tobill for Day Habilitation Services;(c) Ensure that all staff are qualified and properly supervised;(d) Ensure that the service provided is consistent with the person’s ISP/POC, and that services arecoordinated with all other providers;(e) Develop a quality assurance system to evaluate the effectiveness of services provided;(f) Maintain the required staff-to-person ratio, indicated on the person’s ISP/POC, to a maximumstaffing ratio of 1:4;(g) Participate in the annual ISP/POC meeting;(h) Ensure that services are provided appropriately and safely;(i) Develop a staffing plan which includes licensed professionals, where applicable and appropriate;(j) Maintain records which document staff training and licensure, for a period of not less than six (6)years;(k) Offer the Hepatitis B vaccination to each person providing services, pursuant to these rules;(l) Provide training in infection control procedures consistent with the requirements of theOccupational Safety and Health Administration, U.S. Department of Labor, as set forth in 29 C.F.R. §1910.1030; and(m) Provide interpreters for non-English speaking persons and those with hearing impairments thatDDS agrees with requirement for experience with supporting people who are medically or behaviorally complex. Other recommendations are relevant for the General Provisions.ADD: The Small Group Day Habilitation Program Manager of the provider agency must have at least three years of experience working with people with IDD who are medically or behaviorally complex.(See page 58 of the Waiver Amendments)GeneralDecember 23, 2014 meeting with Amy Brooks, Arthur Ginsburg, Ron JamesDDS should require PCT training for all QIDDPs (not just owner/operators) who provide waiver services and supports.Owners-operators shall complete Person-Centered Thinking training.No change required. DDS agrees and this is already a proposed waiver amendment for all provider owner-operators.(See pages 58, 61, 63, 65, 70, 98, 99, 102, 114, 120 and 124 of the Waiver Amendments.)Small Group Day HabilitationKathleen Bjerknes, UCPDCRecommends changing the rate to accommodate the rental and utilities costs and supplies for programming (e.g. Cultural Arts program) If DDS wants to significantly improve Day programming to integrate into the community, this category needs to be increased. Having everyone in the community will cost more. Recommends an increased overall rate of $37.54. Currently large group Day Hab rate is $15.20 per hour or $18,969.60 annually (calculated using 208 days per year). Proposed large group rate is $29,556. Proposed small group rate is $44,892/annually. Changing the rate to $37.54 would change the annual pay to $46,972.Considerations include:Supplies for programming – medical, personal care supplies, activities, program enhancements, trip fees. Transportation – public transportation (metro/buses), parking, van, fuel, vehicle insurance, tag/title, vehicle repair. Rental cost for facility – costs more per square foot to rent smaller spaces until can build partnerships with other community organization.Utilities-electricity, gas, water. Should be increased slightly.Telephone – Must include technology (internet) service and IT support, regular telephones and technology devices (ipad/smart phones) that will be used when out in the community to make accurate notes.Staff training – made no change to this category.Building maintenance- cleaning, repairs, security, snow removal, pest control.Noted. DDS agrees with programming and transportation costs.Small Group Day Habilitation K. BjerknesSuggests using local funds to finance facility improvements, especially if a program has a great idea for a certain group of people.No change required.Noted.GeneralDecember 1, 2014 Public Forum participantParticipant asked what the responsibility of the provider is to ensure that people can participate in community events such as attending church.No change required.DDS needs to develop guidelines around how to keep people safe while mitigating risks. DDS wants people to be exposed to meaningful activities in the community and will engage in capacity building surrounding that.Day HabilitationDecember 1, 2014 Public ForumParticipant asks whether providers need one RN per 20 people? The Day Habilitation services rate methodology to be changed to include nursing for staff training and oversight of Health Care Management Plans (HCMPs) at a ratio of 1:25 to be paid at the rate for a Registered Nurse of $72,800. No change required.An RN is required for supervision, but each nurse need not be an RN. This will be clarified in the regulations.The rate methodology has been updated to reflect change in RN rate to $72,800 and ratio of 1:25 persons. (See Appendix J)Day HabilitationDecember 1, 2014 Public ForumCan providers raise ratio and add LPN ?The Day Habilitation services rate methodology to be changed to include nursing for staff training and oversight of Health Care Management Plans (HCMPs) at a ratio of 1:25 to be paid at the rate for a Registered Nurse of $72,800.No change required.An RN is required for supervision, but each nurse need not be an RN. This will be clarified in the regulations.The rate methodology has been updated to reflect change in RN rate to $72,800 and ratio of 1:25 persons. (See Appendix J)Day HabilitationDecember 1, 2014 Public ForumWhat kind of transportation can be provided for non-medical (community and at home)?No change required.DDS will discuss with MTM. Day HabilitationDecember 1, 2014 Public ForumSuggests adding language to clarify how large groups can be to avoid segregation. Is there a cap on the numbers that can be in the group at the same time?Services are in group settings, butwithin these settings, individuals may receive services as part of a group or on an individualized basis. COMMUNITY OUTINGS (SUCH AS GOING TO A SHOW OR SPORTING EVENT) MAY OCCUR IN GROUPS WITHOUT LIMITATION TO SIZE. INDIVIDUALIZED COMMUNITY INTEGRATION AND/ OR INCLUSION ACTIVITIES MUST OCCUR IN THE COMMUNITY IN GROUPS THAT DO NOT EXCEED 4 PARTICIPANTS AND MUST BE BASED ON THE PEOPLE’S INTERESTS AND PREFERENCES. (See page 57 of Waiver Amendments)Transportation/ Day serviceDecember 1, 2014 Public ForumWill DDS incentivize the use of WMATA? It would be cost effective.No change required. Rates already include funding for transportation and WMATA is one option.In Home SupportsDecember 1, 2014 Public ForumDDS should include in definition memberships and helping people develop friendships in the community.In-Home Supports focus on achieving one or more goals as outlined in the approved Plan of Care utilizingteaching and support strategies. Specified goals are related to acquiring, retaining, and improving independence,autonomy, and adaptive skills. Examples of trainings include the following:? Self-help skills, including activities of daily living and self-care;? Socialization skills to foster community inclusion and well-being;? Cognitive and Communication Tasks Adaptive Skills; and? Replacement Behavior Components of Positive Behavior Support Plans, including those skills required toeffectively address situations and antecedents of frequently occurring maladaptive or challenging behavior. In-Home Supports providers may work as directed by an assigned professional to assist the individual to developskills necessary to reduce or eliminate episodes in which the individual becomes a danger to self or others.DDS agrees.In-Home Supports focus on achieving one or more goals as outlined in the approved Plan of Care utilizing teaching and support strategies. Specified goals are related to acquiring, retaining, and improving independence, autonomy, and adaptive skills. [ADD: The service shall offer adult, skill building activities, including opportunities for community exploration, inclusion and integration, based upon the person’s current, emerging and newly discovered interests and preferences.? The activities shall support the acquisition of new skills as well as support for self-determination, the development of relationships, community integration, employment exploration and/ or community contribution.]? (See page 62 of the Waiver Amendments)Examples of trainings include the following:? Self-help skills, including activities of daily living and self-care;? Socialization skills to foster community inclusion and well-being;Implementation of home therapy programs under the direction of a licensed clinician.? Cognitive and Communication Tasks Adaptive Skills; and? Replacement Behavior Components of Positive Behavior Support Plans, including those skills required toeffectively address situations and antecedents of frequently occurring maladaptive or challenging behavior. In-Home Supports providers may work as directed by an assigned professional to assist the individual to developskills necessary to reduce or eliminate episodes in which the individual becomes a danger to self or others.ADD: Community exploration aimed at discovery of new and emerging interests and preferences. Community activities aimed at supporting the person to have one or more new relationships.Supporting the person to build community membership. (See page 62 of Waiver Amendments)Art TherapiesDecember 1, 2014 Public ForumCertification for music and arts should change to be open to those beyond the one certification.Art therapists certified to practice art therapy by the American Art Therapy Association, Inc. and/orcredentialing of the Art Therapy Credentialing Board. Music Therapists certified by the Certification Board for Music Therapists (CBMT), managed by the American Music Therapy Association.No change required. Commenter did not provide recommendations for specific certifications to consider, although DDS requested this at the public forum. Rates - Creative Arts TherapiesDecember 18, 2014 Public ForumParticipant states that the proposed rates reflect a lack of knowledge about Creative Arts Therapies. Participant believes that DDS could benefit by taking a look at alternative ways of supporting people.Art Therapies proposed rates are $75 for 45 minutes. Music therapy and art therapy group rates are $25 for 45 minutes. Art therapies may be utilized to “providenecessary information to the individual, family, caregivers, and/or team to assist in planning and implementing plans per the approved ISP/Plan of Care.”No change required. The waiver offers a variety of ways to support a person based upon his or her assessed needs, interests and preferences.RatesDecember 18, 2014 Public ForumParticipant asks whether DDS rate increases mandate salary increases for staff or is it discretionary. Another participant asks whether rates are mandatory or performance based.GeneralNo change required. DDS only requires that Living Wages be paid to DSPs in residential services, the HM/Q wages, providers may decide.RatesDecember 18, 2014 Public ForumParticipant asks whether there are any incentives to keep DSP staff for longer days?GeneralNo change required. Providers have discretion on how to use their rates to provide salary incentives for staff, as needed. The residential and day habilitation rates include over-time. Rates – Supported LivingDecember 18, 2014 Public ForumRN rate is a mistake in SL, 6 bed.Year 3 Rate Model lists rate for RN for SL, 6 bed intensive as $31.84 in grid but description lists new rate at $37.15.DDS agrees. The rate has been corrected. (See Year 3 Rate Model, posted on our website.)Rates – Residential HabilitationDecember 18, 2014 Public ForumDoes Residential Habilitation include transportation services?Residential Habilitation Rates include:(a) All supervision from direct support staff;(b) All nursing provided in the residence for medication administration, physician ordered protocols andprocedures, charting, other supports as per physicians orders, and maintenance of Health Management Care Plan;(c) Transportation;(d) Programmatic supplies and fees;(e) Quality Assurance costs such as Incident Management System and Staff Development and,(f) General and Administrative fees for waiver services.No change required.Yes, the Residential Habilitation rate includes transportation.Rates – Small Group Day HabilitationDecember 18, 2014 Public ForumWhy are rates based upon 80% attendance?See App. J.No change required. DDS is assuming more absences because this service is aimed at people who are medically or behaviorally complex. GeneralPublic Forum – Mattie Holloway, Parent/AdvocateCommenter says the public forum was outstanding and that the transition plan presented is good news for people with disabilities.General.No change required.Thank you.GeneralPublic Forum - Collaborative Solutions for Communities (Luz Haro)Commenter says the presentation was informative and helpful. Commenter believes that the implementation of the new amendments will be successful but believes that people who have disabilities are not completely satisfied with the services they are receiving or the knowledge/skill level of the employees who provide those services.General.No change required.DDS is working on changes to its process for provider choice to improve the availability of information for people who receive supports and their families and to better support informed panion Service – RatesPublic Forum - Vested Optimum Community Services (Lauren Lee, Program Director)Commenter states that the rule (amendment, reg?) should be clear about whether the companion service is subject to the Living Wage. PowerPoint presentation says that the companion service is $4.59/15 minute unit but the proposed amendment draft dated October 29, 2014 says the rate is $4.65/15 minute panion: Add a new service to provide non-medical assistance or supervision in accordance with a person’s assessed needs and plan of care with a rate of $4.65 per 15 minute unit.The Companion Service is covered by the Living Wage. The rate will be tied to the State Plan Personal Care Aide rate, which is $4.65 15/minute unit.Supported EmploymentPublic ForumCommenter believes that providers should be required to provide benefits counseling during supported employment for people with IDD and their families.Supported Employment is:1. Vocational assessments: All vocational assessments, regardless of the individual’s vocational placement, areconducted by supported employment providers;2. Individual placement: A supported employment placement strategy in which an employment specialist (jobcoach) places a individual into competitive employment through a job discovery process, provides training andsupport, and then gradually reduces time and assistance at the worksite;3. Development and on-going support for micro-enterprises owned and operated by the individual. Thisassistance consists of:a. Assisting the individual to identify potential business opportunities;b. Assisting the individual in the development of a business plan, including potential sources of businessfinancing and other assistance in developing and launching a business;c. Identification of the supports that are necessary in order for the individual to operate the business; and,d. Ongoing assistance, counseling and guidance once the business has been launched.Supported Employment - Small Group are services and training activities provided in regular business, industryand community settings for groups of two (2) to eight (8) workers with disabilities. Examples include mobilecrews and other business-based workgroups employing small groups of workers with disabilities in thecommunity. Small Group Supported Employment must be provided in a manner that promotes integration intothe workplace and interaction between individuals and people without disabilities in those workplaces.Personal care/assistance to the individual may be a component part of supported employment, small groupemployment support services, but may not comprise the entirety of the service.DDS agrees. Supported Employment is:1. Vocational assessments: All vocational assessments, regardless of the individual’s vocational placement, areconducted by supported employment providers;ADD: BENEFITS COUNSELING: ANALYSIS AND ADVICE TO HELP THE PERSON UNDERSTAND THE POTENTIAL IMPACT OF WORKING ON HIS OR HER PUBLIC BENEFITS, INCLUDING, BUT NOT LIMITED TO: SUPPLEMENTAL SECURITY INCOME, MEDICAID, SOCIAL SECURITY DISABILITY INSURANCE, MEDICARE, AND FOOD STAMPS. (See page 69 of Waiver Amendments)2. Individual placement: A supported employment placement strategy in which an employment specialist (jobcoach) places a individual into competitive employment through a job discovery process, provides training andsupport, and then gradually reduces time and assistance at the worksite;3. Development and on-going support for micro-enterprises owned and operated by the individual. Thisassistance consists of:a. Assisting the individual to identify potential business opportunities;b. Assisting the individual in the development of a business plan, including potential sources of businessfinancing and other assistance in developing and launching a business;c. Identification of the supports that are necessary in order for the individual to operate the business; and,d. Ongoing assistance, counseling and guidance once the business has been launched.Supported Employment - Small Group are services and training activities provided in regular business, industryand community settings for groups of two (2) to eight (8) workers with disabilities. Examples include mobilecrews and other business-based workgroups employing small groups of workers with disabilities in thecommunity. Small Group Supported Employment must be provided in a manner that promotes integration intothe workplace and interaction between individuals and people without disabilities in those workplaces.Personal care/assistance to the individual may be a component part of supported employment, small groupemployment support services, but may not comprise the entirety of the service. ADD: SMALL GROUP SUPPORTED EMPLOYMENT INCLUDES BENEFITS COUNSELING, DEFINED AS ANALYSIS AND ADVICE TO HELP THE PERSON UNDERSTAND THE POTENTIAL IMPACT OF WORKING ON HIS OR HER PUBLIC BENEFITS, INCLUDING, BUT NOT LIMITED TO: SUPPLEMENTAL SECURITY INCOME, MEDICAID, SOCIAL SECURITY DISABILITY INSURANCE, MEDICARE, AND FOOD STAMPS. (See page 113 of Waiver Amendments)Individuals should be providedinformation to make an informed decision in choosing between supported employment, small group employmentsupports and supported employment individual employment support services.GeneralCarol GrigsbyCommenter believes that the issue of the administration of medications while in the community is in need of revision if we are to advance the community integration of HCBS settings.Currently medications are administered within services by RN’s or with RN oversight of non-licensed Medication Administration personnel or LPN’s. There is currently no protocol for the administration of medications while in the community.No change required.DDS agrees and is in talks with the Board of Nursing about this issue.GeneralCarol GrigsbyCommenter says there is a longstanding issue of inadequate coverage for persons with developmental disabilities in the District that the waiver amendments aren’t intended to address. Commenter states that the Individual and Family Services waiver is at least a year away and the broadening of services to cover people with autism or other DDs is unacceptably distant.No change required.Noted for future waiver amendments.Individualized Day SupportsCarol GrigsbyCommenter believes that many of the proposed amendments to IDS are sound, particularly the new 1:1 ratio and the enhanced orientation requirements.Individualized Day Supports are available both as a one-to-one service for a person, and in small group settingsnot to exceed 1:2.Individual employees who work for Individualized Day Support providers are required to complete DDS approved orientation.No change required.Thank you.Individualized Day SupportsCarol GrigsbyCommenter states that there are many available resources, some of which are mass mailings from DDC and DDS, which should be regularly shared with all IDS providers so that community navigators can target specific developmental opportunities (classes, activities, community integration) for those they serve.General.No change required.DDS hosts a Community of Practice for IDS providers and DDS staff, through which there is sharing of learning and information.Individualized Day Supports– Rates, OtherCarol GrigsbyCommenter believes that the reduction of rates combined with the elimination of the Associates degree requirement threatens to erode the quality of people attracted to serve as community navigators. There is also a risk of losing community navigators who are facing a $2.65/hour pay cut. Commenter recommends implementing a sliding scale system to reward those with higher educational or job experience.Individualized Day Supports rate to be reduced from $24.44 per hour to $21.79 per hour, based on market researchand to promote parity with other individualized supports.No change required.The proposed rate does not decrease the salary for DSPs or community navigators working in IDS. Additionally, the requirement that the DSP have experience working with people with IDD is retained. Providers report that the requirement of an Associates Degree has been a barrier. Individualized Day Supports - RatesCarol GrigsbyCommenter requests clarity on what was referred to in the November 17th presentation as “incentivized rates” for IDS.No change required.Rates for IDS are higher than rates for facility based day supports. Individualized Day SupportsCarol GrigsbyCommenter says that in recognition of individuals’ varied needs, it is important for people receiving 1:2 IDS not to be paired consistently with the same person unless the person chooses to be paired with the same person. Commenter believes that varied social contacts are extremely important and should be facilitated.Individualized Day Supports are available both as a one-to-one service for a person, and in small group settings not to exceed 1:2.No change required.DDS agrees.Individualized Day Supports Carol GrigsbyCommenter says that DDS has changed its earlier stated plan to raise IDS maximum service hours from 30 hours/ week to 40 hours/week. Commenter is requesting an explanation of why this decision was made, what types of comments caused this reconsideration. Commenter says DDS should revisit the 30-hour cap after another year.This service is delivered no more than 40 hours per week, in combination with any other waiver day or vocational support services. This includes Employment Readiness, Supported Employment, or Individualized Day Supports.No change required. Public comments from the previous comment period are posted on the DDS website on the Waiver Amendment Information page. DDS agrees to continue to closely monitor IDS and consider adjusting the hours in a future amendment,Individualized Day SupportsCarol GrigsbyCommenter says that as Dr. Mills continues her assistance to DDS with respect to IDS, feedback should be sought from those who have been receiving these services in their initial phase.No change required.DDS is implementing additional monitoring for IDS and the personal outcomes tool will ask people about their experience with IDS. DDS agrees that feedback from the people using IDS and their families would be helpful.Behavior SupportCarol GrigsbyCommenter acknowledges that the motivation to avoid a heavy handed approach to behavioral support planning is a good one. However, the commenter believes that the tiered approach, particularly with respect to Tier 2 time limits on developing and reviewing the BSP, carries potentially significant risks. The commenter explains that behaviors may be complex without being intensive enough to lead to a Tier 3 placement, and curtailing the amount of upfront time spent on getting these plans right could lead to poor BSPs and conceivably behavior escalation. Limitations on time availability for BSP developers already creates a tendency toward “cookie cutter” BSPs which should be avoided. Commenter suggests greater flexibility in time limits for Tier 2 is warranted before the waiver amendments are resubmitted.Development of a new BSP = 5 hours;Review and updating of existing BSP = 3 hours;Training for the person, person’s family, residential and day staff, and support team = 8 hours;On-site consultation and observation = 10 hours;Participation in behavioral review meetings or support team meetings = 10 hours;Quarterly reports and monthly data monitoring = 10 hours;Participation in psychotropic medication review meetings = 4 hours; andCounseling hours= 26 hours.For tier 3 behavioral supports, the following hours shall be permitted:Development of a new BSP = 12 hours;Review and updating of existing BSP = 8 hours;Training for the person, person’s family, residential and day staff, and support team = 20 hours;On-site consultation and observation = 24 hours;Participation in behavioral review meetings or support team meetings = 20 hours;Quarterly reports and monthly data monitoring = 12 hoursParticipation in psychotropic medication review meetings = 4 hours;andCounseling hours = 52 hours.DDS agrees to remove the specific breakdown of time limitations in the proposed service definition and keep the caps at the levels we are proposing. (See page 76 of the Waiver Amendments)Supported Employment Provider RequirementCarol GrigsbyCommenter says that the requirement that supported employment providers also be RSA providers is very welcome and will help increase coordination between DDA and RSA in the employment arena.Supported Employment providers must be enrolled as a provider for Rehabilitation Services Administration (RSA) within oneyear of becoming a supported employment provider.No change required.Thank you.RatesCarol GrigsbyCommenter believes that the proposed rate increases appear well justified while the significant reduction in the rate for fitness counselors seems odd. Commenter suggests that the extent of the reduction of the fitness rate should be revisited to assess the potential effects on the availability of counselors to work with persons receiving DDS support.Fitness: Based on current market conditions, to reduce the rate from $75 to $50 per hour, and to introduce a group rate of $45 an hour.DDS agrees to keep fitness at the current rate of $75 per hour.(See Appendix J)Increase of Waiver CeilingCarol GrigsbyCommenter states that while raising the ceiling in the number of people served is most welcome, the 1742 limit only serves to illustrate how few individuals with developmental disabilities in the District are actually able to be reached with DDS services.Waiver Years 4 and 5 Increase in Participants: Increase the unduplicated number of participants in Waiver Years 4 and 5 from 1,692 to 1,742.No change required.Due to budgetary constraints, DDS will not increase the unduplicated number of waiver participants in waiver years 4 and 5. There will be no impact on current waiver participants.? DDS agrees that supports are needed for adults with developmental disabilities, including autism, who do not have a co-occurring intellectual disability.Rates - FitnessSimi’a Abdul-hakim, PresidentHakim Life & Wellness(ahakim1022@)Commenter is concerned that the proposed amendment to reduce the rate for fitness service from $75 to $50 will have significant economic effects on Hakim Life & Wellness. The commenter believes that the lower reimbursement rate will result in a decrease in service providers, delayed services for consumers and economic difficulties for small community based businesses. Rate reduced from $75 per hour to $50 per hour; group rate $45 per hour.DDS agrees to keep fitness at the current rate of $75 per hour.(See Appendix J)#### ................
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